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Format
• Short Cases• A series of short questions• Review of answers• Discussions
Case 1
• 28 y.o. male• Front seat passenger• Car ran into lamp post• Brought to A&E• No other injury except for severe pain in right
hip
28 y.o. maleFront seat passenger
Questions
1. What is the diagnosis?2. What is the usual position of the limb in this
condition?3. What are the radiological signs?4. What other investigations?5. What are the potential complications? 6. What is the definitive treatment?
1. What is the diagnosis?
2. What is the usual position of the
limb in this condition?
3. What are the radiological signs?
4. What other investigations?
5. What are the potential
complications?
6. What is the definitive treatment?
Anatomy:Hip Joint
Ball and socket joint.Femoral head: slightly asymmetric, forms 2/3 sphere.Acetabulum: inverted “U” shaped articular surface.Ligamentum teres, with artery to femoral head,
passes through middle of inverted “U”.
Hip Dislocation: Mechanism of Injury
Almost always due to high-energy trauma.Most commonly involve unrestrained
occupants in MVAs.Can also occur in pedestrian-MVAs, falls from
heights, industrial accidents and sporting injuries.
Physical Examination: Classical Appearance
Posterior Dislocation: Hip flexed, internally rotated, adducted.
Position of Limb
Adducted, flexed and
Internally Rotated
Diagnosis:Posterior
Dislocation
What are the radiological signs?
Shenton’s LineHead is higherLess trochanter is higher
How do you know that this hip is internally rotated?
Potential Complications
1. Recurring instablility2. Traumatic degenerative arthritis3. Avascular Necrosis4. Sciatic Nerve injury5. High energy injury – watch out for other
blunt trauma that may not be apparently initially
Blood Supply to Femoral Head
1. Artery of Ligamentum Teres2. Ascending Cervical Branches
Sciatic Nerve
Composed from roots of L4 to S3.Peroneal and tibial components differentiate early,
sometimes as proximal as in pelvis.Passes posterior to posterior wall of acetabulum.Generally passes inferior to piriformis muscle, but
occasionally the piriformis will split the peroneal and tibial components
Associated Injuries
Mechanism: high-energy, unrestrained occupants
Thus, associated injuries are common:
• Head and facial injuries• Chest injuries• Intra-abdominal injuries• Extremity fractures and dislocations
Clinical Management: Emergent Treatment
• Dislocated hip is an emergency.
• Goal is to reduce risk of AVN and DJD.
Emergent Reduction
• Allows restoration of flow through occluded or compressed vessels.
• Decreased AVN with earlier reduction.• Requires proper anesthesia.• Requires “team” (i.e. more than one person).
Summary of Posterior Dislocation of the Hip
• Hip is very stable• Require high energy to dislocate• Reduce early with adequate sedate of GA• Patient usually young so complications has
long lasting disability– AVN– Traumatic Arthritis– Recurrent instability– Sciatic nerve injury
Case 2Presenting complaints • 52/ F/ Chinese/ Hawker by profession had to
give up her profession as she was having progressive right hip pain x 4/12 before seeking the consultation
• No significant past medical history of taking any long term medication, trauma or steroid or alcohol use
Clinical examination
• Could still squat with difficulty• Internal and external rotations grossly
restricted and painful
TAH/52/F/Chinese
TAH/52/F/Chinese
Case 2
1. What is the diagnosis? 2. What are the possible causes?3. What are the radiological signs?4. What are the treatment options?
Answer
• What is the diagnosis?– Avascular Necrosis
Answer
• What is the diagnosis?– Avascular Necrosis
• What are the possible causes?
Answer
• What is the diagnosis?– Avascular Necrosis
• What are the possible causes?– Excessive Alcohol consumption– Steroid Use– Rapid Decompression– Trauma– Inflamatory Disease – Lupus (vasculitis)– Gaucher’s Disease
What are the radiological signs?
Crescent Sign
What is the reason for increase density in avascular necrosis?
• Impaction of trabecular bone• New bone on dead trabecular bone• Relative disuse osteopenia
What are the treatment options?
• Analgesic• Weight Reduction• Walking aids• Coring decompresion• Bone Graft• Osteotomy• Hip Replacement
Treatment – Hip Replacement
Case 370 y.o. patient with bilateral hip pain started about 10 years ago. He underwent right hip surgery 5 years ago and left hip surgery 3 years ago.1.What surgeries have been performed?2.What is the indication for surgery?3.Name 3 possible complications of this type of surgery?
Case 3What surgeries have been performed?Bilateral Cement Total Hip Replacements
Case 3What is the indication for surgery?Severe pain and limited walking
Case 3Name 3 possible complications of this type of surgery?1.Neuro-vascular injury2.Dislocation3.Leg length discrepancy4.Infection5.Loosening of implant6.Deep vein thrombosis
Case 4
• 80 yo women, fell at home and sustain this fracture
• Except for hypertension she has no other medical problem
• Lives at home with her daughter and grandchildren
Case 4
1. What is the injury?2. What are the risk factors
for this type of injury?3. What is the
recommended treatment?
4. Name 3 factors that would affect this patient’s post-op recovery
Case 4
• What is the injury?Displaced femoral neck fracture.
Femoral Neck Fracture
• Intracapsular• Subcapital, Transcervical, Basilar• Displaced vs Undisplaced
Un-displaced
Caution!
• Elderly patient • Hx of fall • Subsequently unable to walk• Xray is negative for fracture
Fracture until proven otherwise
Impacted
Displaced
Hip FractureFemoral Neck
Hip Fracture
Leg is:
-Shorten
-Externally Rotated
Case 4
What are the risk factors for this type of injury?
• Smoking• Estrogen Deficiency• Low Calcium Intake• Sedentary lifestyle• Recurrent Fall• Impaired Eyesight• Alcoholism
OsteoporosisSingh Index
Case 4
• What is the recommended treatment?
Hemiarthroplasty
Un-displaced femoral neck fracture
Pinning for Undisplaced or Impacted Fracture of the Femoral Neck
Case 4
• Name 3 factors that would affect this patient’s post-op recovery
1. Pre-morbid ambulatory status
2. Pre-morbid medical condition
3. Pre-morbid mental status
Complications of Femoral Neck Fractures
• Fracture– Avascular Necrosis– Non-union
• Patient– Morbidity– Mortality
Case 5
• 75 y.o. man slip and fell at shopping mall
• Previously healthy.• On no medication• Lives alone in HDB flat
Case 5
1. What are characteristics of this fracture that determine its prognosis?
2. What is the standard of care for this type of fracture?
3. What are the potential complications directly related to the fracture?
Case 5
• What are characteristics of this fracture that determine its prognosis?
Stable versus unstableAs determined by the
fragmentations of the fracture.
Stable vs Unstable Fractures
Stable Unstable
Stable vs Unstable Fractures
Stable Unstable
Case 5
• What is the standard of care for this type of fracture?
Closed reduction and internal fixation with dynamic hip screw
Treatment of Inter-trochanteric Fractures
• Fracture– Closed Reduction and Internal Fixation
• Patient– Early mobilization– Medical management
Closed Reduction
Internal Fixation withSliding Hip Screw
Internal Fixation withSliding Hip Screw
Case 5
• What are the potential complications directly related to the fracture?
Failure of fixation Malunion
Complications of Intertrochanteric Fractures
• Fracture– Stability– Failure of Fixation
• Patient– Morbidity– Mortality
Failure of Fixation
5% in Stable Fractures
20% in Unstable Fractures
Patients with Hip Fractures General Principle of Treatment
Principles of Treatment of Hip Fractures
• Fracture – Provide Stability of Fracture• Patient– Early mobilization – Day 1 post-operative– Minimize medical complications
Aim is to Decrease Medical Complications
• Bed sore• Confusion• Proactive management of bowel and bladder
function (UTI and Constipation)• Deep vein thrombosis• Pneumonia • Careful management of co-morbid medical condition• Adherence to “Pathways” Protocol
Factors influencing Hip Fracture Outcome
• Pre-injury physical status• Pre-injury mental status• Home companion• Nutrition• Independent community ambulation• Post-op ambulation• Post-op complication
Factors Influencing Discharge to Home
• General Medical Condition• Living with someone at Home• Ability to walk 2 weeks after surgery• Mental status
Range from 95% to 25%
Mortality
• About 20%• Stabilize after 12 months• Highly age related• Mental status and general medical conditions
are important factors